CQC report explained · a nursing home
What the CQC found at Oaktree Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2022
Requires Improvement; inspectors found better staffing and nutrition support, but concerns about the building, agency staffing, social isolation and management checks.
Inspectors visited without notice on 26 October and 1 November 2022. They spoke with people, relatives and staff, observed care, and checked care, medicine, food and staffing records.
There had been improvements since the previous inspection in staffing levels and support for eating and drinking. Medicines, safeguarding, recruitment and access to health professionals were also found to be generally safe or effective.
However, the home relied heavily on agency staff, and care quality varied depending on who was working. People often spent long periods in their bedrooms, activities were not always well known or accessible, and parts of the building were damaged or difficult to clean.
The overall rating remained Requires Improvement. The home breached regulations about the condition of the premises and the systems used to monitor quality and safety. The provider was asked for an action plan and will be monitored.
Medicines
Medicines were stored, given and checked safely. Staff administering them had training and their competence was checked each year.
“People received their medicines safely. There were systems for ordering, administering, and monitoring medicines.” from the report
Protection from abuse
Staff understood how to report safeguarding concerns, and recruitment checks were in place to help ensure staff were suitable.
“People were protected from the risk of abuse.” from the report
Food and drink records
The home had improved its monitoring of people's food and fluid intake. Managers checked the records during daily walkarounds and acted when entries needed correcting.
“Improvements had been made to ensure people were eating and drinking sufficient and compliance had been achieved against the breach in regulation.” from the report
Health support
Health professionals gave positive feedback about staff recognising concerns and arranging visits. Staff used handovers to share changes in people's needs.
“Care staff have escalated their concerns to us appropriately, and requested visits as needed” from the report
Building and infection risks
seriousSeveral surfaces, fittings and items were cracked, split, broken or difficult to clean. These problems created infection control risks and were not identified by the home's audits.
“This meant these areas would be difficult to clean.” from the report
Heavy agency use
needs fixingThe home had improved staffing numbers but still used about 700 hours of agency care staff each week. People and relatives said care could vary depending on who was working.
“As noted at the last inspection there continues to be a high agency usage within the home with approximately 700 care hours of agency staff being used on a weekly basis.” from the report
Weak quality checks
seriousThe provider's checks did not identify problems with decoration, fixtures, fittings and infection control. This meant the provider did not have effective oversight of the home's condition.
“Audits and quality assurance checks did not identify the issues found on inspection such as décor of the home and the infection control risks in respect of the environment.” from the report
- 01Which repairs and refurbishment identified in the action plan have now been completed, especially the damaged flooring, toilets, sinks, furniture and bedroom areas?
- 02How many agency staff are now being used each week, and how do you ensure they know each person's preferences and care needs?
- 03How will you make sure people are supported to spend time in shared areas, attend activities and avoid long periods alone in their bedrooms?
- 04How do your current audits identify damage, cleaning problems and infection control risks before they affect people's safety?
- 05How are you recording and reviewing minor concerns, call-bell delays and feedback about inconsistent care?
This was a focused inspection of Safe, Effective, Responsive and Well-led; Caring was not inspected and the overall rating used the previous rating for any key questions not covered. This explanation was written from the published report of 1 December 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2022
Requires Improvement; inspectors found kind care, but there were serious staffing and food and drink monitoring problems.
This was an unannounced planned inspection on 8 December 2021. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, food and fluid, recruitment and quality records.
The overall rating was Requires Improvement. Safe, Effective, Responsive and Well-led were also Requires Improvement. Caring was rated Good. Inspectors found people were generally treated kindly, but there were not always enough suitable staff and records did not show that people at risk were eating and drinking enough.
The home was in breach of two regulations about staffing and nutritional and hydration needs. The provider had an action plan and was recruiting staff, but some known problems had not yet been fixed. The previous rating was also Requires Improvement, published in April 2019.
Kind and respectful care
Inspectors observed friendly, dignified care. People and relatives were positive about the kindness and compassion of staff.
“We observed kind and caring interactions, where people were supported with dignity and respect.” from the report
Medicines managed safely
The home had systems for ordering, giving and checking medicines. Staff who supported people with medicines had training and competency checks.
“Medicines were safely managed. There were systems for ordering, administering, and monitoring medicines.” from the report
Infection control
Inspectors were assured that the home followed infection prevention measures, including PPE, testing, visiting arrangements and outbreak planning.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Activities and family contact
People had access to activities, entertainment, church services and opportunities to see or contact relatives in line with guidance.
“People were supported to see their friends and loved ones in line with government guidance.” from the report
Not enough staff
seriousThe home sometimes had two or three staff fewer than needed, particularly when agency staff cancelled or there was short-notice sickness. This affected staff morale and created a potential risk to people.
“People were not always protected from risk because the provider failed to deploy enough suitably qualified, competent and experienced staff.” from the report
Food and drink records incomplete
seriousFood and fluid charts for people at risk were not completed properly. This meant staff might not know when someone had not eaten or drunk enough and needed more support.
“Systems were either not in place or robust enough to demonstrate where people were at risk of malnutrition and dehydration their needs were being met.” from the report
Quality checks had not led to improvement
needs fixingThe home had identified problems with food and fluid charts, but the same shortfall remained at the inspection.
“Although the provider and the registered manager had identified that food and fluid charts had not been completed fully in November 2021. No improvements had been made to address the shortfall.” from the report
Some communication and choice issues
minorA notice board and menu were out of date in one dementia unit. People were not consistently offered two plated meal choices to help them decide what to eat.
“The notice board in Primrose was not up to date and therefore could be misleading to people in the home.” from the report
- 01How many permanent staff and agency staff usually work on each floor, and what happens when shifts are cancelled or staff are off sick?
- 02How do you now check that people at risk of weight loss or dehydration are offered and receive enough food and fluids?
- 03How quickly are care plans reviewed when a person's needs change, especially when agency staff are working?
- 04What action has been taken in response to the two breached regulations, and what evidence can you show that the problems have been fixed?
- 05How are people living with dementia offered meaningful choices at mealtimes, including the two plated meal choices mentioned in the report?
This was an unannounced planned inspection covering all five CQC questions and infection prevention and control; the report says this was the first inspection for the newly registered provider, while the previous service rating was from April 2019. This explanation was written from the published report of 12 January 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Oaktree Care Home
9 rated inspections over 8 years: the service has improved, from Inadequate to Requires improvement.
- December 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2022Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- April 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2018Requires improvementdown from GoodSafe: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2015Requires improvementstayed Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- July 2015Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- May 2015InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2020
Registered with the Care Quality Commission on 31 July 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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39 live-in carers within about an hour of South Gloucestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,280 a week. 32 can care for a couple. 11 years' experience on average.
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.